AIRWAY

MANAGEMENT
ANATOMY
• The upper airway consists of the pharynx, nose, mouth,
larynx, trachea, and mainstem bronchi.
• The laryngeal structures in part serve to prevent
aspiration into the trachea.
• At the base of the tongue, the epiglottis functionally
separates the oropharynx from the laryngopharynx (or
hypopharynx)
• The epiglottis prevents aspiration by covering the glottis—
the opening of the larynx —during swallowing
• The sensory supply to the upper airway is derived from the
cranial nerves
• The olfactory nerve (cranial nerve I) innervates the nasal
mucosa to provide the sense of smell
• The glossopharyngeal nerve also innervates the roof of the
pharynx, the tonsils, and the undersurface of the soft palate
• The vagus nerve (cranial nerve X) provides sensation to the
airway below the epiglottis
• Another branch of the vagus, the recurrent laryngeal nerve,
innervates the larynx below the vocal cords and the trachea
The effect of laringeal nerve injury on the voice
ROUTINE AIRWAY MANAGEMENT
Routine airway management associated with general
anesthesia consists of:
• Preanesthetic airway assessment
• Preparation and equipment check
• Patient positioning
• Preoxygenation (denitrogenation)
• Bag and mask ventilation
• Intubation or placement of a laryngeal mask airway (if
indicated)
• Confirmation of proper tube or airway placement
• Extubation
AIRWAY ASSESSMENT
Assessments include:
• Mouth opening
• Mallampati classification:
Class I : The entire palatal arch, including the
bilateral faucial pillars, is
visible down to the bases of the pillars.
Class II : The upper part of the faucial pillars and most
of the uvula are visible.
Class III : Only the soft and hard palates are visible.
Class IV : Only the hard palate is visible.
• Thyromental distance
• Neck circumference
EQUIPMENT
The following equipment should be routinely available for airway
management:
• An oxygen source
• Capability to ventilate with bag and mask
• Laryngoscopes (direct and video)
• Several ETTs of different sizes with available stylets and bougies
• Other (not ETT) airway devices (eg, oral, nasal, supraglottic
airways)
• Suction
• Pulse oximetry and CO2 detection
• Stethoscope
• Tape
• Blood pressure and electrocardiography (ECG) monitors
• Intravenous access
ORAL AND NASAL AIRWAYS
• Loss of upper airway muscle tone  the tongue and
epiglottis to fall back against the posterior wall of the
pharynx
• Repositioning the head or a jaw thrust is the preferred
technique for opening the airway.
• An artificial airway can be inserted through the mouth or
nose to maintain an air passage between the tongue and
the posterior pharyngeal wall
• The length of a nasal airway can be estimated as the
distance from the nares to the meatus of the ear and
should be approximately 2 to 4 cm longer than oral
airways.
• Nasal airways (and nasogastric tubes) should be used
with caution in patients with basilar skull fractures.
FACEMASK DESIGN AND TECHNIQUE
• The use of a face mask
can facilitate the delivery
of oxygen or an anesthetic
gas from a breathing
system to a patient by
creating an airtight seal
with the patient’s face
• Transparent masks allow
observation of exhaled
humidified gas and
immediate recognition of
vomitus.
POSITIONING
• When cervical spine pathology is suspected, the head
must be kept in a neutral position during all airway
manipulations.
• Inline stabilization of the neck must be maintained during
airway management in these patients, unless appropriate
cervical radiographs have been reviewed and cleared by
an appropriate specialist.
• Patients with morbid obesity  30° upward ramp as the
functional residual capacity (FRC) of obese patients
deteriorates in the supine position
PREOXYGENATION
• Preoxygenation with face mask oxygen should precede all
airway management interventions.
• Considering the normal oxygen demand of 200 to 250
mL/min, the preoxygenated patient may have a 5 to 8 min
oxygen reserve.
• Conditions that increase oxygen demand (eg, sepsis,
pregnancy) and decrease FRC (eg, morbid obesity,
pregnancy, ascites) reduce the apneic period before
desaturation ensues.
BAG AND MASK VENTILATION
• Bag and mask ventilation (BMV)
is the first step in airway
management in most situations,
with the exception of patients
undergoing rapid sequence
intubation or elective awake
intubation.
• Effective mask ventilation
requires both a gas-tight mask
fit and a patent
airway.
SUPRAGLOTTIC AIRWAY DEVICES
Laryngeal Mask Airway

• LMA consists of a wide-bore tube

whose proximal end connects to a
breathing circuit with a standard
15-mm connector, and whose
distal end is attached to an
elliptical cuff that can be inflated
through a pilot tube.
• The LMA partially protects the
larynx from pharyngeal secretions
(but not gastric regurgitation), and
it should remain in place until the
patient has regained airway
reflexes.
TABLE 19–4 Advantages and disadvantages of the laryngeal mask airway
compared with face mask ventilation or tracheal intubation.1
Esophageal–Tracheal Combitube
The esophageal–tracheal
Combitube consists of two
fused tubes, each with a 15-
mm connector on its
proximal end
King Laryngeal Tube
The King laryngeal tube
consists of a tube with a
small esophageal balloon
and a
larger balloon for placement
in the hypopharynx
ENDOTRACHEAL INTUBATION
• ETTs have been modified for a variety of specialized applications.
• Flexible, spiral-wound, wire-reinforced ETTs (armored tubes) resist
kinking and may prove valuable in some head and neck surgical
procedures or in the prone
patient.
LARYNGOSCOPES
• A laryngoscope is an
instrument used to
examine the larynx and
to facilitate intubation of
the trachea.
• The Macintosh and
Miller blades are the
most popular curved
and straight designs,
respectively, in the
United States.
VIDEO LARYNGOSCOPES
Varieties of indirect
laryngoscopes include:
• Various Macintosh and
Miller blades in pediatric
and adult sizes have video
capability in the Storz DCI
system.
• The McGrath
laryngoscope is a portable
video laryngoscope with a
blade length that can be
adjusted to accommodate
the airway of a child of age
5 years up to an adult
• The GlideScope
comes with disposable
adult- and pediatric-
sized blades
• Airtraq is a single-use
optical laryngoscope
available in pediatric
and adult sizes
Flexible Fiberoptic Bronchoscopes
INDICATION OF INTUBATION
• Patients who are at risk of aspiration and in those
undergoing surgical procedures involving body cavities,
the head and neck,
• Those who will be positioned so that the airway will be
less accessible
OROTRACHEAL INTUBATION
SURGICAL AIRWAY TECHNIQUES
• “Invasive” airways are
required when the “can’t
intubate, can’t ventilate”
• The options include
surgical cricothyrotomy,
catheter or needle
cricothyrotomy,
transtracheal catheter
with jet ventilation, and
retrograde
intubation.
COMPLICATIONS OF LARYNGOSCOPY &
INTUBATION
TERIMA KASIH